Take 2 paracetamol and call me in the morning

During elder clinic last week I saw a woman with a swollen leg. She said that it had been that way for about 4 months. The local government hospital attributed it to a sprained ankle and told her to take a paracetamol and go home. She not presented to the CCS elder clinic complaining that her leg was still "paining" her and persistently swollen. My nurse asked me if I wanted to refill her paracetamol as the other doctors had done in past months. Taking one look at her leg, I could tell that this was no sprained ankle as the edema was up to her hip! In addition to a pelvic mass compressing her lymphatic vessels, I was concerned about possible filariasis - a disease endemic and common in most tropical regions. Because the clinic was in a state of repair and reorganization, I was hosting clinic in a makeshift office with little to no patient privacy. Knowing that there was little chance of conducting a thorough examination during the short visit, I arranged for the patient to meet me at Navajeevana clinic the following day. When we were able to properly examine her, a large, grapefruit-sized hard mass was protruding from her hip below the skin. It was dense and irregular, but painless. We ordered an AP pelvis, which showed a large mass which had eroded the anterior column and part of the iliac wing of her pelvis! She said that the mass had been there for some time, but because it wasn't painful, she assumed that it couldn't be anything bad - so she ignored it. When the doctors at the government hospital said that her swollen leg was due to a sprained ankle, she had no reason not to believe them.

It's an interesting thing about cancer in eastern cultures. You don't talk about it. Even if you have to talk about it... you do so in a manner that you don't actually talk about it. There is one cancer hospital in Sri Lanka - Maharagama. We were not able to directly refer our patient to this hospital. Instead, she would have to first be seen by the OPD (outpatient department) officer - a junior doctor stuck with the duty of triaging all patients before being seen by the more prestigious consultant doctors. He would ultimately have the decision making power to admit her to the cancer ward. If he decided not to admit her - then she would die at home with no recourse. The only thing we could do was hand write a letter on her behalf - gently suggesting to the OPD doctor to let her into the cancer hospital. If we were too directive, then the OPD doctor might get offended and take it out on the patient. If she had money and could bribe the OPD, then she could get a bed tonight! There are only two radiation oncology centers in the country - one broken most of the time. The remaining machine serves the entire multimillion population.

Tomorrow I go to the National Teaching Hospital of Sri Lanka - the top government hospital. I'm hoping to set up some times where I can round with the inpatient service. Should be fun!